LAUSR

The purpose, if any, that medical colleges could or do serve in 2017 is uncertain. The future college role might be constrained to professional and technical evaluation of doctor competence and up-skilling. The sentinel question is whether or not the medical guilds can become effective socially beyond intrinsic guild-need and play a role in preventing and mitigating, and in responding to, health system failures. Medical colleges have long been a part of the ‘health system architecture’. The Royal College of Surgeons (RCS) arose first as the Guild of Surgeons within the City of London in 1368. An agreement in 1493 resolved a consequential long-standing dispute between the surgeons and the barber-surgeons (from whose unqualified ranks the quaint habit of the titular Mr, and now similar feminine forms, arose instead of Dr). In 1540, Henry VIII formed the Company of Barber Surgeons as a union of the Worshipful Company of Barbers and the Guild of Surgeons. The surgeons broke away from the barbers to form the Company of Surgeons in 1745, and the RCS in London was created by way of a royal charter in 1800. The RCS in London is nevertheless well predated by the Barber Surgeons of Dublin, who were incorporated in 1446 by a royal decree from Henry VI, and just preceded in 1505 by the Barber Surgeons of Edinburgh, who were formerly incorporated as a Craft Guild of Edinburgh. In response to considerable lobbying from physicians and apothecaries, and sometime after similar regulatory interventions elsewhere in Europe, Henry VIII also formed the Royal College of Physicians by a royal charter in 1518, followed by an Act of parliament in 1523. There is no doubt about the craft-guild origins of the medical colleges and/or their longevity. The question to be debated is do the colleges still have any utility or are they anachronisms? To balance this historical introduction, it needs to be acknowledged that increasing patient safety by way of practitioner regulation was a strong element of the foundation debates. Critics of the medical profession, such as Roy Porter, argue that the sociological construct of the medical colleges has proven resilient and that they remain craft guilds. It is tautological then to argue that colleges are self-serving, as this is a central purpose and function of any guild. Both Porter, and other critics, such as Ivan Illich, would also suggest an alternative market-control (i.e. patch-protection and/or constraint-of-trade) rationale for practitioner regulation that is masked by patientsafety rhetoric. They would accept the various colleges’ public health affirming mottos but counter that craft guilds have always used community-service-type ‘platforms’ to advance their own causes, and in the case of health, sometimes at the expense of societal best interests. The history of medicine is littered with atrocities perpetuated by and/or tolerated by the medical profession, and by doctor-led health system failures; notwithstanding the considerable good for which the medical profession has been responsible, the unanswerable question in this context is why have the medical guilds repeatedly failed in their core and founding ‘patient-safety’ mission? Recent British examples of such systemic failures, which resulted in considerable patient-harm, such as in Bristol, and about a decade later in Mid-Staffordshire, suggest that little is learnt and that medical colleges are, at best, somewhat passive bystanders. Similarly, contemporary treatment injury data do not illustrate contextual college efficacy. Extrapolating from the most recent annual report of New Zealand’s comprehensive and no-fault Accident Compensation Corporation, treatment injury costs will soon exceed those of any other source of injury (i.e. either road traffic accidents, or industrial and domestic accidents). In the USA, medical error is now reported as the third most common cause of death, exceeded only by heart disease and cancer. The late Professor Sir John Scott and I argued that not only had the medical guilds ‘medicalised’ society, but also that medical practice had become consequentially socially distorted. We saw no real winners in the interaction. We also noted what we regarded as the classic definition of professionalism, which was made early in the 20th century by Justice Brandeis of the United States Supreme Court. He listed the peculiar characteristics of a profession as: